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MONITORING WELL INSTALLATION REPO <br /> Date: CONSTRUCTION //'' <br /> Premise Address: IZ 7r- Total Depth � U <br /> .!l�' t Screen Length (from) (to) <br /> � <br /> Well No.: �& Filter Pack (from) /SfU (to)_ <br /> Bentonite (from) (to) <br /> Grout (from) (to) <br /> Inspector: <br /> Drilling rig type <br /> Permit No. �5�7J � Auger O.D. et 0- I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: <br /> height <br /> Consultant T <br /> 71, <br /> Geologis <br /> ABOVEGROUND CHRZIY-BOX <br /> COMPLETION COMPLETICN <br /> SPECIAL PERMIT INFO. nd Sort <br /> i proof <br /> Distance to sewer line L��0 <br /> Domestic well on site - (y In tt• <br /> / <br /> If yes, location and distance - Z ft. <br /> D n. _ <br /> = m <br /> — o <br /> = m <br /> SAMPLING slotted = ,X <br /> socion <br /> Holding Temperature <br /> Method = <br /> Screening Method = <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank Screen <br /> Slot size uo <br /> GROUTING Bags cement 6 JL- <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios =a 2 (� i 80 3a/o Filter Pack type/size /Z — <br /> installation Method Surge Block: - (y/ nn <br /> Quantity Installed_ Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br /> /� A/ �� % , <br />